Discoid Lupus Erythematosus (DLE)

What discoid lupus is

In discoid lupus, the immune system attacks the skin's hair follicles and the junction between the top skin layers. Ultraviolet light and smoking are major triggers. Lesions go through stages: red, inflamed patches with scale, then plugged follicles, then scarring with thin, pale centers and dark rims.

Discoid lupus is one type of cutaneous lupus. It can occur alone or as part of systemic lupus erythematosus (SLE), which affects internal organs. About 1 in 5 people with SLE have discoid lesions at some point.

Symptoms

• round, coin-shaped (discoid) red or purple patches with a thick, adherent scale
• enlarged, plugged hair follicles that look like small spines when the scale is lifted ("carpet tack" sign)
• patches on the cheeks, nose, ears (especially the bowl of the ear), scalp, lips and neck
• scalp involvement with permanent, scarring hair loss, a common and distressing feature. See alopecia
• mild itching or tenderness, though many patches do not hurt
• as patches heal: depressed scars, light patches (hypopigmentation) in the center, and dark rims, which are especially visible on darker skin
• localized DLE stays above the neck. Widespread DLE involves the body too and carries a higher risk of SLE

Causes and risk factors

• autoimmunity with genetic susceptibility
• sun exposure (UVA and UVB), which triggers and worsens lesions
• smoking, linked to more severe disease and poorer response to hydroxychloroquine
• female sex and age 20 to 40
• Black ancestry
• trauma to the skin, such as scratches or tattoos, can trigger new lesions

Diagnosis

1. Examination by a dermatologist.
2. Skin biopsy confirms the diagnosis and distinguishes it from psoriasis, fungal infection, sarcoidosis and skin cancer.
3. Blood and urine tests screen for SLE: complete blood count, ANA and other antibodies, complement levels, kidney function and urine for protein and blood.
4. Regular rechecks for signs of systemic disease, especially in the first years.

Treatment

Starting treatment early reduces permanent scarring and hair loss.

Sun protection and smoking

• broad-spectrum sunscreen with SPF 50 every day, reapplied every 2 hours outdoors
• wide-brimmed hats, UV-protective clothing, and window film
• stop smoking

Skin treatments

• High-potency steroid creams or ointments applied to active patches, used in cycles to limit skin thinning
• Steroid injections into thick or scalp lesions
• Calcineurin inhibitors (tacrolimus, pimecrolimus), especially for the face

Tablets for widespread or resistant disease

• Hydroxychloroquine, an antimalarial, is first-line. It takes 2 to 3 months to work. Regular eye exams are needed to check for retinal toxicity
• other options: methotrexate, mycophenolate, dapsone, retinoids (acitretin), thalidomide, and newer agents in trials. Anifrolumab, approved for SLE, has shown benefit in cutaneous lupus

Cosmetic support

Camouflage makeup, hair pieces, and, once disease is inactive, laser or surgical treatments for scars.

Complications

• permanent scarring and pigment change
• permanent bald patches
• squamous cell carcinoma developing in long-standing scars, particularly on the lips. Any new lump, ulcer or bleeding in a scar needs checking
• progression to SLE in a minority
• emotional distress and reduced quality of life

Outlook

Discoid lupus is usually chronic, with flares and quieter periods. Some cases go into long remission. Early treatment, strict sun protection and not smoking give the best results. Regular follow-up catches signs of systemic lupus early.

Frequently asked questions

What does discoid lupus look like?

It looks like round, red or purple, scaly patches, usually on the face, ears and scalp. As they heal, they leave depressed scars with pale centers and darker edges. Patches on the scalp often cause permanent bald spots.

Is discoid lupus the same as systemic lupus?

No. Discoid lupus mainly affects the skin. Systemic lupus can affect the joints, kidneys, blood, heart, lungs and brain. About 5 to 25% of people with discoid lupus go on to develop systemic lupus, so regular checks are important.

Can discoid lupus be cured?

There is no cure, but it can be controlled. Sun protection, steroid creams or injections and hydroxychloroquine calm active patches and prevent new ones. Some people have long remissions. Scars from past lesions remain.

Does discoid lupus cause hair loss?

Yes. Discoid lupus on the scalp destroys hair follicles, causing scarring hair loss that is usually permanent. Treating active scalp patches early can preserve hair that has not yet been lost.

Can sunlight make discoid lupus worse?

Yes. UV light is a major trigger for new patches and flares. Daily broad-spectrum sunscreen, protective clothing and avoiding peak sun hours are an essential part of treatment, even in winter and on cloudy days.